Selected abstracts submitted to the Third International Symposium on Hereditary Breast and Ovarian Cancer

Selected abstracts submitted to the Third International Symposium on Hereditary Breast and Ovarian Cancer BRCA: Fifteen Years of Progress, Third International Symposium on Hereditary Breast and Ovarian Cancer; October 14–16, 2009; Centre Mont-royal, Montreal, Quebec, Canada The opinions expressed in the abstracts are those of the authors and are not to be construed as the opinion of the publisher (Multimed Inc.), the organizers of the Third International Symposium on Hereditary Breast and Ovarian Cancer, or the Hereditary Breast and Ovarian Cancer Foundation. Although the publisher (Multimed Inc.) has made every effort to accurately reproduce the abstracts, Multimed Inc. and the organizers of the Third International Symposium on Hereditary Breast and Ovarian Cancer, or the Hereditary Breast and Ovarian Cancer Foundation assume no responsibility and/or liability for any errors and/or omissions in any abstract as published. Determination of Molecular Profiles of BRCA1 and BRCA2 Breast Cancers G. Banneau,* M. Guedj,† R. Schiappa,† F. Petel,† N. Sévenet,* I. De Mascarel,* G. Mac Grogan,* M. Longy,* F. Bonnet.* *Institut Bergonié, INSERM, Unit-M – U916 VINCO, Bordeaux, and †Ligue Nationale Contre le Cancer, CIT – Recherche, Paris, France. Background: Germline mutation screening of BRCA1 and BRCA2 genes is performed in suspected familial breast cancer cases, but a causative mutation is found in only 30% of patients. The development of additional methods to identify good candidates for BRCA1 and BRCA2 analysis would therefore increase the efficacy of diagnostic mutation screening. With this in mind, we developed a study to determine molecular signatures of BRCA1—or BRCA2—mutated breast cancers. Materials and Methods: array-cgh (comparative genomic hybridization) and transcriptomic analysis were performed on a series of 103 familial breast cancers. The series included 7 breast cancers with a BRCA1 mutation and 5 breast cancers with a BRCA2 mutation. The remaining 91 cases were obtained from 73 families selected on the basis of at least 3 affected first-degree relatives or at least 2 affected first-degree relatives with breast cancer at an average age of 45 years. array-cgh analyses were performed on a 4407 BAC-array (CIT-V8) manufactured by IntegraGen. Transcriptomic analyses were performed using an affymetrix Human Genome U133 Plus 2.0 chip. Results: Using supervised clustering analyses we identified two transcriptomic signatures: one for BRCA1-mutated breast cancers consisting of 600 probe sets and another for BRCA2-mutated breast cancers also consisting of 600 probes sets. We also defined cgh-array signatures, based on the presence of specific genomic rearrangements, one for BRCA1-mutated breast cancers and one for BRCA2-mutated breast cancers. Conclusions: This study identified molecular signatures of breast cancers with BRCA1 or BRCA2 germline mutations. Genes present in these signatures could be exploited to find new markers for such breast cancers. We also identified specific genomic rearrangements in these breast cancers, which could be screened for in a diagnostic setting using fluorescence in situ hybridization, thus improving patient selection for BRCA1 and BRCA2 molecular genetic analysis. Identification and Characterization of Splice Variants in BRCA Genes Using Reverse Transcriptase Polymerase Chain Reaction and Multiplex Ligation-Dependent Probe Amplification R.D. Brandão,*† K. van Roozendaal,* D. Tserpelis,* E. Goméz García,*† M.J. Blok.* *Department of Clinical Genetics, University Hospital Maastricht, and †GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, Limb, Netherlands. Objectives: A large subset of the unclassified variants in the BRCA1/2 genes are in intronic sequences or close to exon–intron boundaries and may affect splicing. Putative BRCA1 and BRCA2 splice variants, as predicted in silico, were studied experimentally using reverse transcriptase polymerase chain reaction (rt-pcr) and a new approach based on multiplex ligation-dependent probe amplification (mlpa) technology. Methods: Short-term lymphocyte cultures from controls and unclassified sequence variant carriers were established with pha and il-2. analysis by rt-pcr was performed for the following BRCA2 putative splice variants: c.425G>T, c.6935A>T, c.6842–3T>C, c.6943A>G, c.7976+3del2, c.8350C>T, c.8662C>T, c.8754+3G>C. The use of mlpa technology was subsequently evaluated for the detection of aberrant splice events on well-characterized splice variants, including BRCA1 exon 13 and exon 22 deletions. Commercially available mlpa kits for BRCA1 and BRCA2 genes were used (probes in exons), in addition to homemade mlpa probe sets (probes crossing exon–exon boundaries). Results: BRCA2 variants c.425G>T and c.7976+3del2 give rise to transcripts with deletions of exon 4 and exon 17 respectively, and c.8754+3G>C leads to 46 bp of intron retention. These variants were considered to be pathogenic. additionally, alternative splicing events were observed in controls, such as c.6842_6937del (exon 12 skipping) and c.476_631del (exon 6 and 7 skipping). Because these in-frame transcripts are also expressed in healthy controls and have an unknown function, their clinical relevance remains unclear. This has consequences for the classification of c.6935A>T, which leads to increased expression of c.6842_6937del compared with controls. We found that, with mlpa, it is also possible to detect alternative splicing events. Conclusions: We characterized several new pathogenic BRCA2 splice variants and demonstrated that, with mlpa technology, it is possible to set up a multiplex screen for semi-quantitative detection of alternative splice events that is also widely applicable for genes other than BRCA1/2. P001 P002 APPLIED RESEARCH

Germline mutations in BRCA1 and BRCA2 genes cause predisposition to breast and ovarian cancers. Here, we describe the experience of our Human Genetics Center on a total of approximately 700 patients living in the southern part of Belgium. These patients, apparently from independent families, were referred by oncologists or by geneticists. all of them had a personal and/or familial history suggestive of genetic predisposition to breast and/or ovarian cancer.
The entire coding regions of the BRCA1 and 2 genes were screened by standard scanning methods (denaturing gradient gel electrophoresis, denaturing high-pressure liquid chromatography, or high resolution melt), followed by sequencing of abnormal profiles. Large rearrangements of the two genes were investigated by mlpa (multiple ligation-dependent probe amplification from MRC-Holland).
A total of 186 variants (excluding known polymorphisms) were identified (106 in BRCA1, 80 in BRCA2). This represents a detection rate of 26.5%.
A causal mutation has hence been identified in a total of 17.5% of the patients (11.4% in BRCA1, 6.1% in BRCA2). These results underline the role of large rearrangements of BRCA1 (16.25% of the mutations identified in this gene) in Belgium and point to the need for collaborative efforts to classify precisely variants of uncertain significance, because they represent 33.8% of all variants detected.
Mutations in PALB2 have been reported to be associated with a doubled to tripled increased risk of breast cancer. Women with mutations in PALB2 who also have a strong family history of breast cancer are predicted to be at a high absolute risk for the disease comparable to that in women who carry BRCA2 mutations. a current paucity of information about PALB2 mutation carrier risks prevents testing for mutations in this gene being incorporated into evidenced-based clinical genetics services.
Objectives: To conduct a large case-control family study using population-based and clinic-based resources, to characterize PALB2 mutations in terms of breast cancer risk, and to devise criteria to identify women most likely to carry PALB2 mutations.
Methods: High-resolution melt curve analysis and Sanger sequencing. Results: To date, we have screened 756 early-onset population-based cases for PALB2 mutations and identified 2 carriers, both in women with extremely strong family histories of breast cancer. We have also screened 400 women from multiple-case breast cancer families and identified 4 families that carry PALB2 mutations. Testing for these mutations in relatives has identified an additional 20 PALB2 mutation carriers. Breast cancers arising in affected female carriers are commonly grade 3 (7/12 reviewed to date) and estrogen receptor-positive (7/9 reviewed to date); 9 are infiltrating ductal carcinomas, and 3 are lobular or pleomorphic lobular carcinomas.
Conclusions: We and others have produced preliminary and circumstantial evidence that women who carry a mutation in PALB2 are at an elevated risk of breast cancer, and that depending on family history, these risks could be of clinical relevance comparable to that for women with BRCA2 mutations. PALB2 mutations are rare, but for the women who carry these mutations and their families, it is potentially important that mutations be identified so that the women can be offered appropriate prevention, screening, and clinical management.

Recurrent BRCA1 Mutations Identified in Manitobans of Eastern
European Descent a E. Spriggs,* † ‡ T. Dyck,* R. Jobse,* B. Chordirker † ‡ § A. Chudley † ‡ § S. Marles † ‡ § K. Serfas, § Julie Richer. || *Clinical Biochem and Genetics, Diagnostic Services of Manitoba; † Department of Biochemistry and Medical Genetics and ‡ Department of Pediatrics and Child Health, University of Manitoba; and § Genetics and Metabolism Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba; and || Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada. approximately 1 in 5 people living in the Canadian province of Manitoba are of Eastern European descent, with Ukraine being the most frequently named country of origin. Mutations in BRCA1 and BRCA2 account for most hereditary breast and ovarian cancers. Ten years ago, testing for BRCA1 and BRCA2 mutations in Manitoba was limited to the three common mutations found in the ashkenazi Jewish population, and shortly thereafter included screening by protein truncation testing. Through results obtained in-house and from published data, it became recognized that one of the three common mutations, BRCA1 c.5266dupC (5382insC), was also common in individuals of European descent, particularly those from Eastern Europe. Twelve unrelated Manitoban families were identified with the c.5266dupC mutation over the first 8 years of BRCA1 and BRCA2 genetic testing in Manitoba, and of these, only 4 (30%) are from families of Ashkenazi Jewish descent. The remaining cases were found in families reported to be of Ukrainian (n = 5), Polish (n = 1), Hungarian (n = 1), and German/unknown (n = 1) descent, with no known Jewish background. Given this observation and the relatively high proportion of the Manitoba population being of Eastern European descent, an ethnicspecific panel targeted to individuals of Eastern European descent was created. It included three BRCA1 mutations (c.5266dupC, p.Cys61Gly, c.4034delA) that were described in literature as "recurrent" for this population. Over the past 3 years, 55 Manitobans have been tested, and two new families with mutations in BRCA1 were found, one with c.5266dupC and one with p.Cys61Gly. The c.5266dupC case, representing our 13th family, was identified in a woman of Ukrainian/German Mennonite descent who had bilateral breast cancer. The p.Cys61Gly was found in a Ukrainian family with a history of breast and ovarian cancer. A second unrelated family of Ukrainian descent was identified with the p.Cys61Gly mutation through denaturing high-pressure liquid chromatography mutation scanning of the BRCA1 and BRCA2 genes. as part of our full screen available to affected patients who meet our testing criteria for BRCA1 and BRCA2, a novel and yet recurrent BRCA1 genomic deletion involving exons 13 through 19 was identified in 3 unrelated Manitoban families, with Ukrainian descent being the only common theme. data accumulated thus far suggest that the founder BRCA1 mutations for Manitobans of Eastern European descent are similar to those described by others, c.5266dupC and p.Cys61Gly, and that this unique in-frame deletion involves exons 13-19. a Published in Genetics in Medicine [In press].

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The Mennonites are a distinct ethnic and religious group characterized by their Anabaptist beliefs and pacifism. Over the last few centuries, persecution forced this group to migrate throughout Northern and Eastern Europe, and then to Southern Manitoba (Canada), the American Midwest, Mexico, and Central and South America. There are about 66,000 Mennonites residing in the Canadian province of Manitoba, accounting for approximately 6% of its total population. Founder mutations have been identified in the Mennonite population for a number of genetic diseases, including hypophosphatasia, X-linked congenital stationary night blindness, and familial hypertrophic cardiomyopathy. We have identified a mutation, c.5238dupT (p.Asn1747fs), in the BRCA2 gene in 4 unrelated Mennonite families. The index patients were referred for genetic testing of BRCA1 and BRCA2 genes because of personal and family histories of breast and ovarian cancer. One family also had a history of pancreatic cancer. Of the 4 families, 3 were long-time residents of Manitoba; 1 family had recently emigrated from Bolivia. Further investigations into the pedigrees did not reveal any common relatives between the families. These mutations were independently identified by dna sequencing following the observation of a truncated band using the protein truncation test targeted to exon 11 of BRCA2. The c.5238dupT mutation has been reported only a limited number of times in the Breast Cancer Information Core database and in the literature, and it has been restricted to patients of dutch, German, Mennonite, and Western and Eastern European descent. The finding of 4 large pedigrees of Mennonite descent indicates the presence of a founder mutation in the Manitoba Mennonite population. The population frequency of this BRCA2 c.5238dupT mutation among Manitoba Mennonites is not known, but it may be of value to offer targeted mutation analysis to individuals of Mennonite descent who have a personal and/or family history of breast and ovarian cancer. However, it is important to note that other mutations, such as BRCA2 c.6952C>T (p.Arg2318X), have been identified in Manitoba Mennonites with strong family histories of cancer. Such families that meet testing criteria and do not carry the c.5238dupT mutation should be offered full screening for BRCA1 and BRCA2.  BRCA1 and BRCA2 are the two major high-risk breast cancer susceptibility genes, and the scale of clinical mutation screening of these genes probably exceeds that of any other set of cancer susceptibility genes. One complication resulting from genetic testing is that between 5% and 15% of patients screened are found to carry an unclassified sequence variant (uv). Observations of uvs create problems for the clinical lab staff who initially detect the uvs through to the patients who receive the ambiguous information.
The Breast Cancer Information Core has developed a Bayesian integrated evaluation of uvs based on co-segregation, personal and family history, tumour histopathology, and co-occurrence of variants in trans. Integrated evaluation includes a prior probability based on these in silico analyses of the substitutions, both from the perspective of potential effects on mrna splicing and potential effects on protein function. To facilitate the evaluation of BRCA1 and BRCA2 uvs, we created the BrCa International agency for research on Cancer (iarc) database. This database contains the set of all possible single nucleotide substitutions (which constitute a sizeable preponderance of all uvs) to the open reading frames of BRCA1 and BRCA2. In silico analysis programs can be run on this finite set. The BRCA iarc database summarizes predicted potential to interfere with mrna splicing (MaxEnt and NNSplice) and predicted missense substitution severity (position and Align-GVGD, using curated protein multiple sequence alignments) on the entire set. These scores are integrated to give a prior probability of pathogenicity for each substitution. Thus the database, and the Web site through which we present it (brca.iarc.fr/), provides a starting point for the integrated evaluation of most BRCA1 and BRCA2 uvs.

Objectives:
The clinical relevance of most non-truncating mutations in the BRCA1 and BRCA2 genes, including amino acid substitutions, is unknown. The assessment of these unclassified variants (uvs), which is of crucial importance for appropriate risk management, requires a multimodal approach.
Methods: By integrating classical genetic, tumour histopathologic, functional, evolutionary conservation, and computational approaches, we investigated the pathogenic nature of a missense mutation, D1739V (c.5216A>T, p.Asp1739Val), of the BRCA1 gene identified in 2 of our breast/ovarian cancer families.
Results: The d1739V variant showed complete co-segregation in both families, loss of the wild-type BRCA1 allele with retention of the variant allele in tumour-derived dna, a BRCA1-like genomic profile in a breast tumour from an uv carrier, and loss-of-function in transcriptional activity assays. d1739 is located within the brct domain of BRCA1. a protein multiple sequence alignment containing 13 BRCA1 orthologs from different species showed complete evolutionary conservation of d1739. Computational analysis using the align-GVGD method classifies D1739V as highly likely to interfere with normal protein function, based on the evolutionary conservation of d1739 and physicochemical characteristics of the amino acid pair d and V. The functional impact of the d1739V variant was also analyzed by three supervised learning programs, all predicting a deleterious effect. Protein modeling of the brct domain of BRCA1 suggested that d1739V disrupts the conformational stability of this domain.
Conclusions: all types of data generated in this study support a pathogenic nature of the variant d1739V, and we therefore propose to classify this amino acid substitution as a deleterious BRCA1 mutation. Objectives: Breast cancer is the most common cancer to affect South african women, with a lifetime risk of 1 in 13 for the afrikaner. discovery of the BRCA genes introduced a new era for genetic testing, for not only could affected patients be informed regarding their risk for other cancer types, but other at-risk relatives could also be identified. The discovery of these genes urged many countries, including South africa, to launch investigations into the prevalence of mutations in these genes.
Methods: a total of 157 afrikaner breast and/or ovarian cancer families (≥3 cases) were screened using conventional polymerase chain reaction analyses. Families carrying identical mutations were genotyped to determine whether the mutations resulted from independent events or a common ancestor. a genetic counselling protocol, based on classical clinical counselling strategies, was developed for patients requesting testing.
Results: BRCA1 mutations accounted for 19% (30/157) and BRCA2 mutations for 47% (73/157) of mutation-positive families. Three recurrent mutations were identified, two in BRCA1, 1493delC and E881X, and one in BRCA2, 8162delG. Genotype and genealogical analyses indicated common ancestors, with a specific European founding couple identified for each. Collectively, the 3 Afrikaner founder mutations accounted for 94% (97/103) of BRCA mutation-positive families. a diagnostic testing protocol has since been implemented. Because of incomplete penetrance, preliminary investigations into potential single-nucleotide polymorphisms revealed that homozygosity for the variant allele of WAF1 IVS2+16C→G proved to be associated with an increased breast cancer risk among BRCA2 mutation carriers affected with breast cancer specifically.
Conclusions: The 3 founder mutations are unique and limited to the South african afrikaner population. The uniqueness could possibly be attributable to both mutations being de novo occurrences in one of the founders; or the particular mutations might be extremely rare in the European populations from which the forefathers originally came; or lastly, both mutations were initially present in the European populations, but have become extinct.
Nowadays genetic testing for hereditary breast cancer is offered worldwide. In about 20% of familial cases, the disease-causing mutations can be identified; the rest remain unexplained. Many of these mutations occur in the high-penetrance breast cancer genes BRCA1 and BRCA2. a limited percentage are attributable to pathogenic mutations in moderate-penetrance genes such as CHEK2.
Objectives: In leuven, the familial cases are routinely tested for mutations in the BRCA1/2 genes. To study the involvement and the implications of the specific c.1100delC CHEK2 variant in breast cancer, a large cohort of affected patients has been tested for the presence of this mutation. The collected data have been analyzed and discussed for possible further clinical service.
Methods: The presence of the c.1100delC mutation was assessed by multiplex ligation-dependent probe amplification (P-045 MRC-Holland). The positive samples have been subsequently sequenced for confirmation.
Results: The frequency of the c.1100delC mutation in Belgian patients is 3.4%-very close to the frequency found in the Netherlands. Compared with BRCA1/2 mutations, this CHEK2 mutation was more frequent in bilateral breast cancer patients and in patients with an age of onset over 46 years. Our data are also consistent with the observation that the CHEK2 gene is a multi-organ gene.
Conclusions: although the CHEK2 gene is a moderate-risk breast cancer gene, these data can be taken into account because of the implications for clinical practice. Given that the relative risk of breast cancer for CHEK2 by age 60 is 6%-10% (vs. 30%-60% for BRCA1/2), clinical follow-up for patients carrying the c.1100delC mutation has been adapted to become more stringent. The frequency of this mutation in Belgium warrants its implementation in the diagnostic service. Background: Breast cancers attributable to underlying germline BRCA1 and BRCA2 mutations are associated with particular pathologic features that may differ from those of sporadic breast cancers. We report clinical and pathologic characteristics of breast cancer in Chinese women with and without mutations and of carriers of BRCA1 mutations as compared with BRCA2 mutations.

Clinical, Pathologic, and Genetic Characteristics of Chinese Patients with BRCA-Related Breast Cancer
Methods: Based on age and family history, 226 high-risk women were recruited from March 2007 to November 2008. Medical information was prospectively collected from the patients and medical records. BRCA1 and BRCA2 mutations were detected using full gene sequencing and multiplex ligation-dependent probe amplification.
Results: Of the 226 female probands tested, 28 women (12.4%) were BRCA mutation carriers, and among these carriers, 11 (39.3%) had BRCA1 and 17 (60.7%) had BRCA2 mutations. The BRCA mutation carriers were more likely to have a familial history of breast and ovarian cancer, high-grade cancers, and triple negative (tn) cancers. Prevalence of tn was 48.3% in BRCA carriers and 25.6% in non-carriers; it was 67.7% in BRCA1 and 35.3% in BRCA2 carriers. Estrogen receptor-negative cancer was significantly associated with BRCA1 mutations, especially in those under 40 years of age (odds ratio: 5.14; confidence interval: 1.03 to 25.60). In this cohort, one recurrent BRCA2 mutation was found in 4 probands, accounting for 23.5% of BRCA2 mutations and 14.3% of all BRCA mutations. The haplotype analysis confirmed the recurrent mutation c.3109C>T to be a founder mutation of Southern Chinese.
Conclusions: BRCA-related breast cancer in this Chinese population is associated with family history and adverse pathologic and prognostic features, with BRCA2 mutations being more prevalent, but BRCA1 carriers having more aggressive and tn cancers. Compared with Caucasian populations, the prevalences of BRCA2 mutations and tn cancer are elevated.

Genetic Cancer Risk Modifiers in Hereditary Breast and/or
Ovarian Introduction: Variability observed in penetrance, age of onset, and site of the tumour, both among and within BRCA families, suggests that other lowpenetrance genetic variants modify the cancer risk.
Objectives: To study the effect of 6 polymorphisms, recently described as being risk modifiers of sporadic breast cancer (bc) or ovarian cancer (oc) in BRCA families.
Conclusions: We found evidence that certain polymorphisms involved in hormone-mediated cell proliferation and apoptosis modify the bc and oc risks in BRCA families. This may be relevant for an individual assessment of the most suitable preventive option among those currently available for each of those patients.

Genome-Wide Linkage Analysis of high-Risk Breast Cancer
Families although studies have shown that germline mutations in BRCA1 and BRCA2 account only for approximately half of all site-specific familial breast cancer (bc), to date there has been little success in using a linkage approach to identify further bc susceptibility loci. Thus, it seems likely that there are additional high-penetrance loci to be discovered. In 2006, we published the results of a linkage analysis in 149 multiple-case bc pedigrees. although several regions of interest were identified, no definitive evidence of linkage was found, likely because of genetic heterogeneity. To address this, we have now analyzed a further set of 123 families that were part of an international consortium in familial bc including families from North America (n = 53), Europe (n = 57), and Australia (n = 14). All families had at least 3 cases of bc diagnosed at or before the age of 60 and were previously screened for mutations in BRCA1 and BRCA2. The primary analysis used merlin under a dominant mode of inheritance using the same model as in Smith et al., 2006. Results: The linkage analyses identified one region with a conditional heterogeneity logarithm of odds (hlod) of 2.2, and three others with hlods > 1.0. In a combined analysis of the new and existing data, suggestive evidence of linkage was identified on chromosome 4 (hlod = 2.4, α = 0.15). When families were stratified by the presence of bilateral bc or of 5 or more cases of bc, the evidence (or the linkage) was increased (hlod = 3.3, α = 0.30 and hlod = 3.6, α = 0.26 respectively). To further refine the hypothesized locus on chromosome 4, we genotyped a further 12 short tandem repeat markers spanning the linked region. Fine mapping of likely-linked families has narrowed the region likely containing a bc susceptibility gene to 14.6 cM covering approximately 18 Mb of dna. We are currently sequencing the most plausible candidate genes within this region. The tp53 tumour-suppressor pathway plays a critical role in the progression of a variety of human cancers. among the known regulators, MDM4, a haploinsufficient homologue of MDM2, has been shown to bind and inhibit tp53 protein. as part of a candidate tp53 pathway approach, a statistically significant association with breast cancer (bc) risk was observed at the MDM4 locus in our recent genome-wide association study (gwas) in the Ashkenazi Jewish (aj) population. We observed a large extent of linkage disequilibrium around the MDM4 locus in aj bc cases from our aj gwas, with multiple single-nucleotide polymorphisms (snps) significantly associated with bc risk. analysis of these data revealed a susceptible haplotype and a modestly elevated bc risk [p = 0.01; odds ratio (or): 1.2; 95% confidence interval (ci): 1.01 to 1.45]. To replicate these findings, we genotyped a tagging snp for this haplotype (rs2369244) in independent collections of 654 aj bc cases and 1085 aj controls. Similar to the findings in the gwas cohorts, the minor allele homozygotes were significantly enriched in cases as compared with controls (p = 0.01; or: 1.19; 95% ci: 1.04 to 1.38). Furthermore, a pooled meta-analysis including the gwas data (total of 1133 bc cases and 1351 controls), and controlling for age, suggests that this snp significantly associates with bc risk in aj population. The association was most apparent for minor allele homozygotes (G/G-or: 1.52; 95% ci: 1.18 to 1.95; p = 0.00085). Further replication analysis is being planned as part of an international Breast Cancer association Consortium involving more than 60,000 bc cases and controls of predominantly European ancestry. Besides ongoing functional experiments, the next phase of the study will address possible gene-gene interactions of MDM4 rs2369244 with other critical players in this pathway, including MDM2 snp309 and TP53 r72P, where genetic variation has also been described to be associated with increased risks for other cancer types. The susceptibility gene for ataxia telangiectasia, ATM, is also an intermediaterisk breast cancer susceptibility gene. However, the spectrum and frequency distribution of ATM mutations that confer increased risk of breast cancer have been controversial. To assess the contribution of rare variants in this gene to risk of breast cancer, we pooled data from seven published ATM case-control mutation screening studies including a total of 1544 breast cancer cases and 1224 controls with data from our own mutation screening of an additional 987 breast cancer cases and 1021 controls. Using an in silico missense substitution analysis that provides a ranking of missense substitutions from evolutionarily most likely to least likely, we carried out analyses of protein-truncating variants, splice junction variants, and rare missense variants. We found marginal evidence that the combination of ATM protein-truncating and splice junction variants contribute to breast cancer risk. There was stronger evidence that a subset of rare, evolutionarily unlikely missense substitutions confer increased risk. On the basis of subset analyses, we hypothesize that rare missense substitutions falling in and around the fat, kinase, and fatc domains of the protein may be disproportionately responsible for that risk, and that a subset of these may confer higher risk than do protein-truncating variants. We conclude that a comparison between the graded distributions of missense substitutions in cases versus controls can complement analyses of truncating variants to help identify susceptibility genes, and that this approach will help interpret the data emerging from new sequencing technologies. Uterine leiomyosarcoma (ulms) is a rare gynecologic malignancy with a low survival rate. Currently, there is no effective treatment for ulms. Infrequent occurrences of human ulms hamper the understanding of the initiation and progression of the disease, thereby limiting the ability to develop efficient therapies. To elucidate the roles of the p53 and BRCA1 tumour suppressor genes in gynecologic malignancies, we generated mice in which p53 and/or BRCA1 can be conditionally deleted using anti-Müllerian hormone type ii receptor (Amhr2)-driven Cre recombinase. Mice with a conditional deletion of p53 developed uterine tumours that resembled human ulms. a concurrent deletion of p53 and BRCA1 accelerated the progression of those tumours. Consistent with the hypothesis that BRCA1 plays a role in ulms, we have shown that the BRCA1 protein is absent in 29% of human ulms. We have demonstrated that BRCA1 promoter methylation is the likely mechanism of BRCA1 downregulation in human ulms. Our findings provide a rationale for investigating therapies that target BRCA1 deficiency in ulms.
In response to the 2004 U.K. National Institute for Health and Clinical Excellence Guidelines for Familial Breast Cancer, our screening strategy for the BRCA1 and BRCA2 genes was changed from screening approximately two thirds of each gene using a protein-truncation test and fluorescent heteroduplex analysis to a complete screen of both genes using sequencing and multiplex ligation-dependent probe amplification (mlpa).
Since May 2006, we have screened 564 new referrals and have found BRCA1 or BRCA2 pathogenic mutations in 99 individuals (18%). A variant of unknown significance (vus) has been identified in a further 83 individuals (15%). We have also retrospectively completed a full screen on 738 individuals who previously had a negative two-thirds screen. This involved a significant collaboration with the Clinical Genetics Team who reviewed all individuals seen before January 2000 to ensure that they met current testing guidelines. In this group, BRCA1 or BRCA2 pathogenic mutations were identified in 45 individuals (6%), and a vus was identified in a further 48 individuals (7%). Of the 144 (65 BRCA1, 79 BRCA2) pathogenic mutations identified, 127 (51 BRCA1, 76 BRCA2) were detected by sequencing, and 17 (14 BRCA1, 3 BRCA2) by mlpa. a total of 40 BRCA1 mutations and 44 BRCA2 mutations have been seen in only 1 individual. Of the 11 BRCA1 and 12 BRCA2 mutations that have been identified more than once, most have been seen in only 2 unrelated individuals. However BRCA1 c.4065_4068delTCaa has been seen in 4 unrelated individuals, duplication of BRCA1 exon 13 in 3 unrelated individuals, BRCA2 c.755_758delaCaG in 6 unrelated individuals, and BRCA2 c.7988a>T in 5 unrelated individuals.
In total, 126 different vus have been identified, of which 101 have been seen in only 1 individual. These comprise 68 missense variants (23 BRCA1, 45 BRCA2), 30 synonymous variants (13,17), and 28 intronic variants (8,20). Objectives: The National Comprehensive Cancer Network (nccn) has put forth practice guidelines for hereditary breast and ovarian cancer syndrome (hbocs) management. We here present data on how different physician specialties recommend surveillance for patients who have undertaken genetic testing.

Significant Differences Among Physician Specialties in the
Methods: We conducted an online survey of Texas ama physicians that included random sampling of 5 different specialties: family medicine (fm), obstetrics and gynecology (og), general surgery (gs), internal medicine (im) and hematology-oncology (ho). In 4 hypothetical case scenarios, the physicians were asked to handle hbocs management of unaffected women ages 40-42 years, in the presence of a familial mutation.
Results: The survey was completed by 23% of the physicians (n = 224). For BRCA-negative women, 42% of the physicians (with no clearly significant differences among specialties, p = 0.08) recommended surveillance as set forth by nccn. Using an aggregate screening intensity score, physicians clearly recommended more screening for mutation-positive women than for mutationnegative women; however, only about 3% followed nccn guidelines. For BRCApositive women, 89% of ho/og recommended breast mri, compared with 63% of im/fm (p < 0.0001); 81% of gs/ho, as compared with 35% of im/fm, recommended prophylactic mastectomy (p < 0.0001); and 76% of gs/og/ho, as compared with 45% of im/fm, recommended prophylactic oophorectomy (p < 0.0001). Overall, physicians who had ordered BRCA testing in their practice recommended more intense management of mutation-positive women than did those that had not (p = 0.0059 independent of their specialties) and management that was more intense than specified in the nccn guidelines (p = 0.0015).
Conclusions: although surveillance guidelines and prophylactic surgical options have been established for BRCA mutation carriers, many physicians are not cognizant of these guidelines, including the use of new imaging modalities and appropriate prophylactic surgery. Our study identifies a need to target education of physicians by specialty, so that optimal surveillance and management options can be offered to these high-risk women. Objectives: Mutations in BRCA1 and BRCA2 are associated with an increased risk of breast, ovarian, prostate, and pancreatic cancer. There have been reports of a mild association of BRCA2 mutations with cutaneous and ocular melanoma. We present a rare case of an anal melanoma in a BRCA1 ashkenazi Jewish founder mutation carrier.
Methods: a 62-year-old male of ashkenazi Jewish descent presented with symptoms of anal pain and hematochezia. Sigmoidoscopy revealed an anal mass, and biopsy demonstrated invasive malignant melanoma of the anal canal. Staging work-up revealed liver metastases. Family history was significant for a sister who died at age 30 from breast cancer, and a 40-year-old daughter diagnosed with ovarian cancer at age 36 who tested positive for a BRCA1 mutation, 187delaG. The patient presented for genetic counselling and testing. The patient's peripheral blood was sent for analysis of the three ashkenazi Jewish founder mutations: BRCA1 187delaG, BRCA1 5385insC, and BRCA2 6174delT.
Results: Molecular analysis identified a deleterious mutation, 187delAG, in the BRCA1 gene. This is a frameshift mutation that results in premature truncation of the BRCA1 protein at amino acid position 39. This confirms the diagnosis of hereditary breast and ovarian cancer syndrome (hbocs).
Conclusions: This case represents the first report of an anal melanoma in a BRCA1 carrier and sheds light on an unusual cancer presentation in patients with hbocs. Earlier studies have shown an association between melanoma and BRCA2 mutations, but there has been little-to-no evidence of this association in BRCA1 carriers, especially carriers with ashkenazi Jewish founder mutations. detection of the BRCA1 187delaG mutation in this patient leads to promising therapeutic options using novel systemic agents for this highly aggressive, potentially lethal malignancy.

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Current OnCOlOgy-VOlume 16, number 5 Objectives: Hereditary breast and ovarian cancer syndrome (hbocs) is associated with a mildly increased risk of cutaneous and ocular melanoma. Earlier studies have demonstrated ocular melanoma in association with BRCA2, but not BRCA1, mutations. We present a rare case of an ocular melanoma and primary peritoneal carcinoma in a BRCA1 mutation carrier.
Methods: a 62-year-old Caucasian female presented with an abnormal Papanicolaou smear and underwent a laparotomy, which revealed primary peritoneal carcinoma. Her past medical history was significant for decreased night vision, leading to the diagnosis of a left ocular melanoma (spindle-cell, type B) at age 57 years. She underwent a therapeutic enucleation at that time. Family history is remarkable for early-onset breast cancer in her sister and two nieces, all diagnosed in their 40s. The patient presented for genetic counselling and testing following the diagnosis of primary peritoneal carcinoma. The patient's peripheral blood was sent for full sequence analysis of the BRCA1 and BRCA2 genes. direct dna sequence analysis was performed on the polymerase chain reaction products corresponding to the entire BRCA1 and BRCA2 coding region.
Results: The molecular analysis identified a deleterious mutation, 2530delaG, in the BRCA1 gene. This is a frameshift mutation that results in premature truncation of the BRCA1 protein at amino acid position 808, confirming the diagnosis of hbocs.
Conclusions: The patient described above developed two rare malignancies, ocular melanoma and primary peritoneal carcinoma. Earlier studies have identified a 2%-3% prevalence of BRCA2 mutations in younger individuals with ocular melanoma. This case represents the first report of an ocular melanoma in a BRCA1 carrier and highlights the unusual presentation of cancers in individuals with hbocs.

Detection and Prevention of hereditary Breast Cancer D. Farengo Clark,* S. Mento, † G. Grana.* *Cooper Cancer Institute, Voorhees, New Jersey, and † Arcadia University, Glenside, Pennsylvania, U.S.A.
There is a paucity of data looking at how breast cancers are diagnosed in BRCA carriers and the stage in which these women are diagnosed. Our hypothesis is that BRCA1/2 carriers will more often present with a palpable mass than be identified through imaging and that they will be diagnosed with advanced-stage disease that requires traditional chemotherapy. We also wanted to examine the relationship between mutation status and pathology. We conducted a retrospective evaluation of female breast cancer patients who carried BRCA1/2 mutations to determine how women find their cancers and how those cancers are treated. Our study included 66 women who were diagnosed with breast cancer and who carried a BRCA1/2 mutation. almost half the women presented with palpable masses, but only 1/2 were diagnosed by mammographic findings. Surprisingly, of the 66 cancers, 50 were diagnosed at stage 0-iib, and only 5 were diagnosed at stage iii or higher. BRCA1 cancers were more often triple-negative than were BRCA2 cancers (42% and 21% respectively). Although these cancers were diagnosed at early stages, 92% of BRCA1 carriers and 68% of BRCA2 carriers still were treated with traditional chemotherapy. We feel that, if a woman is presented with this data showing that an impending cancer will more often than not require chemotherapy, she may choose more aggressive management and opt for prophylactic mastectomy. Knowing that BRCA1 cancers are triple-negative may also change recommendations regarding the use of anti-hormonal agents and leave women with fewer prevention options. all of this information should be presented to women to help them make an informed decision about prevention when they receive results.

Objectives:
To evaluate risk factors that may relate to the development of fallopian tube cancer in women with and without a BRCA mutation.
Methods: Subjects with fallopian tube cancer were identified from a large international registry of women that carry a BRCA1 or BRCA2 mutation (n = 56) and from a population-based study of ovarian and fallopian tube cancer in Ontario, Canada (n = 67). BRCA mutation status was established for all subjects. all subjects completed a questionnaire about medical history and lifestyle factors. Subjects were matched with controls for date of birth within 4 years, for BRCA mutation (negative, BRCA1, BRCA2), country of residence, and past history of breast cancer (yes/no and matched within 5 years of diagnosis). Using conditional logistic regression, the odds ratio (or) and 95% confidence interval (ci) were calculated for parity, body mass index, oral contraceptive use, tubal ligation, and hormone replacement therapy.
Conclusions: Parity and oral contraceptive use were associated with a decreased risk of fallopian tube cancer, but these effects were not observed consistently across all groups stratified by mutation. The risk factors for fallopian tube cancer appear to be similar to risk factors for ovarian cancer. Objectives: To determine clinicopathologic characteristics of BRCAassociated prostate cancer in men of Ashkenazi Jewish (aj) ancestry.
Methods: We determined BRCA mutation prevalence in 832 aj men with localized prostate cancer and 435 aj controls, and compared age, stage, prostatespecific antigen, Gleason score (gs), overall survival, and other clinical outcome measures among 26 BRCA mutation carriers and 806 non-carriers. Kruskal-Wallis tests were used to compare age of diagnosis and gs, and logistic regression models were used to determine associations between carrier status, prostate cancer risk, and gs. Hazard ratios were estimated using Cox proportional hazards models.
Conclusions: BRCA2 mutation carriers had an increased risk of prostate cancer, a younger age of onset, and a more aggressive phenotype. Prostate cancer cases with a BRCA1 or BRCA2 mutation were characterized by an adverse clinical outcome. These results may affect clinical management of this subset of hereditary prostate cancer.

CLINICAL MANAGEMENT
Introduction: Breast reconstruction is an important procedure that requires attention to detail for optimal outcome. Spectrum implants (Mentor Corporation, Santa Barbara, CA, U.S.A.) have provided us with the tools to optimally adjust for achieving symmetry and patient satisfaction. Single-staged breast reconstruction with saline implants was first introduced by Becker in 1982. Despite advances in our surgical techniques and prosthesis, the reported complication rate remains high at 28%.
Purpose: We present the senior author's experience over a period of 7 years for immediate and delayed breast reconstruction as it relates to implant reconstruction. This is the first reported study of breast reconstruction using Spectrum Expander/Implant with the use of the same retropectoral technique and no alloderm. All implants were saline-filled.
Methods: a retrospective review analysis of patients undergoing Spectrum implants by the senior author from 2001 to 2008 is presented. Specific attention is paid to factors associated with major complications.
Results: a total of 44 patients underwent 67 Spectrum breast implant reconstructions. The mean age of the study patients was 42.7 years (standard deviation: ±11.6 years; range: 17-67 years). There was no skin necrosis (0%). Complications requiring reoperation and general anesthesia were capsular contracture (n = 10; 14.9%), periprosthetic infection (n = 3; 4.5%), and delayed sudden deflation (n = 2; 3.0%). Only 1 patient was subsequently judged not suitable for reoperation/reconstruction because of severe neutropenia. The subcutaneous valves were removed under local anesthesia during nipple reconstruction without any complication. Photographic technical tips and final results are presented.
Conclusions: Use of a versatile integrated all-in-one expander/ implant (Spectrum) can achieve great results with minimal complication and reoperation rates. Services-Calgary, Breast Health Program, Calgary, Alberta, Canada; and ‡ Queen's University, Kingston, Ontario, Canada. Background: In 2007, funding was obtained to formalize and evaluate the Calgary Breast Health Program high-risk breast cancer clinic, which commenced February 2008. The team included a physician, nurse, psychologist, and clerical assistant. The target client population included individuals at high genetic risk (per medical genetics), women diagnosed with lobular carcinoma in situ or atypical hyperplasia, and women who received mantle radiotherapy in childhood or teenage years. The initial appointment involved self-completion of a needs assessment questionnaire, a brief meeting with the psychologist, breast (± ovarian) cancer risk assessment, overview of screening and risk-reduction options, and a nurse-led discussion of lifestyle strategies and signs or symptoms of breast (± ovarian) cancer. The pilot period was completed in March 2009, and the clinic continues to operate under the same model.

Early Experiences of the Calgary Breast health Program high-Risk Breast Cancer Clinic S. Lupichuk,* † J. Ng, ‡ K. Blaikie, † S. Leith, † T. Power, † B. Walley.* † *Tom Baker Cancer Centre and † Alberta Health
Objectives: To describe the demographic profile of clients; the perceived pre-consultation needs of clients; the recommendations made by the clinic; and the referrals generated.
Methods: all clients seen from February 2008 through May 2009 who agreed to be contacted regarding further research will be sent a consent package. Pertinent information on consenting clients will be abstracted from charts. descriptive statistics will be applied to the data obtained.
Results: By May 31, 2009, the clinic had received 116 referrals, and 73 consultations had been completed. Referrals came from medical genetics (n = 57), primary care (n = 38), surgery (n = 20), gynecology (n = 1), and psychology (n = 1). Of the referrals not seen, most were referred directly to medical genetics (n = 22) or are waiting on a pending appointment (n = 6). For consenting clients seen by the clinic, aggregate data describing demographic profile, perceived preconsultation needs, recommendations made, and referrals made are presented.
Conclusions: The introduction of a formal high-risk breast cancer clinic in Calgary has been a feasible undertaking. assessment and revision of the current clinic model is ongoing.

hereditary Breast/Ovarian Cancer high-Risk Clinic:
Our First 12 Years C. Kim-Sing, M. McCullum, J. Pike, K. Swenerton. BC Cancer Agency, Vancouver, British Columbia, Canada. Objectives: To describe the clinic's first 12 years of experience with highrisk screening for women with confirmed BRCA1 or BRCA2 gene mutations.
Methods: To date, 262 women with BRCA1/2 mutations have seen a clinic physician and nurse specialist for consultation. Prophylactic mastectomy with reconstruction is an option discussed with all women, and high-risk breast screening is offered as the alternative. Screening includes clinical breast exam and imaging every 6 months, with an alternating schedule of breast mri (from age 25) and mammography (from age 30). Prophylactic bilateral salpingo-oophorectomy (pbso) is recommended to all mutation carriers. Ovarian cancer screening is not currently recommended. Women are discharged to their family physician's care after prophylactic surgeries, and those with a new cancer diagnosis or recurrence are referred to an oncologist.
Results: Of BRCA1/2 mutation carriers attending the clinic, 16% have had at least 1 new cancer diagnosis; 46 new cancers have been detected (26 in BRCA1-positive, 20 in BRCA2-positive), with 4 women having 2 new diagnoses. Cancers diagnosed include 24 invasive breast cancers, 7 ovarian cancers, 4 cases of ductal carcinoma in situ (dcis), 2 cases of lobular carcinoma in situ (lcis), 2 fallopian tube (ft) cancers, 2 peritoneal cancers (both after pbso), 2 pancreatic cancers, 1 malignant melanoma, 1 gastric cancer, and 1 colorectal cancer. Of the breast cancers, 10 were identified on mri screening. Six cancers were diagnosed by pathology review at the time of prophylactic surgery, including 3 ovarian cancers, 1 ft cancer, 1 breast cancer, and 1 lcis, with an additional dcis diagnosis on contralateral mastectomy.
Conclusions: Over the past 12 years, the clinic has provided a valuable service to high-risk women in our province. Experienced clinicians offer information, support, referral to expert surgeons, breast imaging, and clinical follow-up. This high-risk clinic will provide ongoing opportunities to evaluate the efficacy of specific cancer risk management strategies.

Effect of Reminder Telephone Calls on Mammography
Compliance in high-Risk Women C. Snyder, H. Lynch. Creighton University, Omaha, Nebraska, U.S.A.
The effect of a reminder telephone call intervention designed to encourage mammography has not been systematically studied in a high-risk population in which compliance is crucial. We hypothesize that a simple reminder telephone call would significantly increase mammography uptake in high-risk women as compared with a control group. In 447 high-risk women, consent to participate in the study was obtained. Interestingly, 346 (77%) of these women self-reported being compliant in obtaining annual mammography for the preceding 2 years. Verification was established in a subset of these women by obtaining their mammogram reports. Subjects who were noncompliant by self-report (n = 32) were randomized to the intervention or the control group. reminder and follow-up telephone calls were completed on 16 women in the experimental group, and follow-up calls were completed on 15 women in the control group. One woman was excluded from the study after being diagnosed with breast cancer upon obtaining a mammogram. A statistical difference (p = 0.0017) was observed between the two groups in support of the hypothesis that mammography compliance in high-risk women can be increased if an intervention such as a simple reminder call is implemented. Future studies should identify barriers in obtaining mammograms in these high-risk individuals. Objectives: To evaluate outcomes and factors affecting uptake of riskreducing salpingo-oophorectomy (rrso) in women at high risk for ovarian cancer over the age of 40 years.

Outcomes and Uptake of Risk-Reducing Salpingo-Oophorectomy in Women Over the Age of 40 Years at high Familial Risk of
Methods: Prospectively collected data of women attending a Familial Cancer Clinic between 2004 and 2009 were analyzed. The preferred management option recommended to women over the age of 40 years with a 10% or greater estimated lifetime risk of ovarian cancer was rrso with peritoneal washings. Those declining surgery opted for screening under the United Kingdom Familial Ovarian Cancer Screening Study. a strict histopathologic protocol with serial slicing was used for rrso specimens.
Results: Of 1518 high-risk women from breast/ovarian cancer families seen from 2004 to 2009, 517 were below 40 years of age. Of the 1001 others, 181 were BRCA1/2 carriers, and 820 had unknown mutation status (ums). Of the 1001 women, 263 (of whom 33.5% were carriers) chose rrso, and 738 (of whom 12.6% were carriers) preferred screening.
The median ages (and interquartile ranges) for the rrso and screening groups were 50.9 (45.3, 57) years and 47.5 (43.2, 54.9) years respectively (p = 0.001). Women undergoing rrso were more likely to have had breast cancer (p < 0.0005), to have a relative below the age of 50 years with ovarian cancer (p = 0.012), to have a parity of P2 or greater (p = 0.039), to be postmenopausal (p < 0.0005), and to carry BRCA gene mutations (p < 0.0005). The median age of women undergoing rrso was lower in BRCA carriers than in ums women (p < 0.000001).
Conclusions: Various factors affect decision-making in high-risk women. BRCA carriers and ums women both have a high occult malignancy rate, and the age at detection of lesions is similar in both groups. It is important that women are made aware of these facts, because ums women tend to delay surgery till becoming postmenopausal. e Equal contribution. In 2007, it was reported that North american medical school curricula are lacking in the area of clinical genetics (Thurston VC et al. Acad Med 2007;82:441-5). Implementation of an online self-directed learning module (slm) provides students with an interactive case-based approach that simulates real-world uses of genetic testing and highlights the implications of such tests on patient decision-making.

MEETING aBSTraCTS
Objectives: To design and implement a slm for medical students to improve their knowledge of hereditary cancers using breast cancer as the model.
Methods: The slm will be designed by a medical student working together with a clinical geneticist and a medical oncologist. The objectives for the module are focused on providing students with knowledge in three areas: • How to interpret a patient's personal and family history to assess level of risk • Understanding the implications of genetic testing as they relate to hereditary cancers • Increasing awareness of the diversity of psychosocial issues facing women and their families who are found to have a BRCA mutation Results: Assessment of the efficacy of this slm as a teaching tool will be carried out using a focus group of medical students. The focus group will examine the effectiveness of the slm in increasing student knowledge and in addressing the limitations of the modality so that those limitations can be overcome.
Conclusions: slms present an excellent opportunity to provide early impact in medical school curricula. By integrating knowledge from several key disciplines (genetics, oncology, and gynecology) with appropriate emphasis on the psychosocial aspects of risk assignment, medical students will have an increased understanding of adult-onset genetic conditions.

Personal Genetics and Cancer Prevention: Mapping Public
Representations and Psychosocial Response to Testing C. Ouellette, R. Hyde-Lay, T. Caulfield. Health Law Institute, Law Centre, University of Alberta, Edmonton, Alberta, Canada.
It has been suggested that the age of personal genetics is here (Hudson, 2009;Walsh, 2009). Indeed, a service offered by the personal genetics company, 23andMe, was named invention of the year for 2008 (Hamilton, 2008). And in the same year, the investigation of genetic variation was deemed the scientific breakthrough of the year by Science magazine. The entire field also gets a tremendous amount of media attention, garnering almost daily coverage in the popular press.
One of the foundational rationales for this emerging field-and the reason for much of the excitement-is that it will allow for a more holistic and preventive approach to the management of chronic diseases, including many forms of cancer (Scheuner et al., 2008). This rationale can be found in both the academic literature and in the marketing strategies of companies offering direct-to-consumer genetic tests. However, current research regarding psychosocial response to genetic testing is mixed, clouding the preventive rationale for the field.
Our study contrasts public representations of risks and benefits with behaviour research. Firstly, we map the psychosocial risks and benefits associated with the emerging field of personal genetics, as communicated through public representations. Secondly, we critically assess the public representation of personal genetics in relation to literature on cancer prevention strategies and its role as a means of health communication. In response to personal genetic testing, how are cancer prevention strategies framed? do the representations support a preventive approach to personal genetics? How might public representations be improved to promote preventive behaviour in response to testing? Our study hopes to provide insight into the current state of public communications and psychosocial response to genetic testing.

Secondary Use of Data and Samples from Deceased Participants:
What Are the Legal and Ethical Constraints? K. Bédard,* E. Lévesque, † D. Avard, † J. Simard. ‡ *Université de Montréal and † Centre of Genomics and Policy, McGill University, Montreal; and ‡ Faculté de médecine, Université Laval, Quebec City, Quebec, Canada. Context: Biologic samples and data used in research may, in some cases, be of great use for another research project. This is called "secondary use." The secondary use of data and samples is current practice among health care researchers, even more so since the increasing use of biobanks. However, particular issues arise when the participant to whom the samples and data are linked is deceased. although ethical and legal framing of secondary use of samples and data of live participants is in place and is consistent across various normative texts, the framework concerning deceased participants is often less developed and sometimes inexistent. although the value of these samples is often inestimable, using them may sometimes prove to be complex.
Methods: Our research consists of an analysis of the legal and ethical framework in place in Quebec and Canada concerning the secondary use of data and samples from deceased individuals. We analyzed how the various norms address some specific questions such as the scope of consent for use after death and considerations concerning the wishes of living relatives related to the use of data and samples of a deceased individual, when there is no prior indication of individual choice.
Results: We will provide a synthesis of the elements that need to be taken into account before considering the secondary use of such material. We will examine, by way of example, the procedure set in place to allow secondary use in the case of the continuation of the inherit breast cancer project, funded by the Canadian Institutes of Health research Team in Familial risks of Breast Cancer. Finally, we will conclude by presenting lessons learned, which could be helpful for the elaboration of a uniform ethical and legal framework in Canada. The presence of a breast cancer case diagnosed before 36 years of age is a strong indicator for the presence of a BRCA1/2 mutation in French-Canadian (fc) hereditary breast and/or ovarian cancer (hbc/hboc) families. Earlier studies were limited by screening for the mutations that recur in this founder population. We have assessed the contribution of BRCA1/2 to 75 hbc and 51 hboc fc families who have at least 3 cancer cases per family and who have undergone Myriad Genetics mutation screening and multiplex ligation-dependent probe amplification analysis for rearrangements. About 50% of the hbc families were mutation-negative. about 32% were 3-case families, in which 71% were mutation-negative (p = 0.014). The distribution of cases relative to an index tested case in the hbc mutation-negative group differed from that in the mutationpositive group (p = 0.004), where more first-degree relatives with breast cancer were observed in the mutation-negative families (56%) than in the mutation-positive families (35%, p = 0.0009). The frequency of breast cancer diagnosed before the age of 36 years in the hbc mutation-negative families (6%) differed significantly from that in the BRCA1 (23%, p = 0.0002) and BRCA2 (23%, p < 1x10 5 ) mutation-positive hbc families. Thus, although 50% of the hbc families harboured a mutation, about 80% of families with at least 1 breast cancer case diagnosed below the age of 36 years were mutation-positive. about 69% of the hboc families were mutation-positive, and as compared with the 19% of mutation-negative families, 54% of those mutation-positive families contained at least 1 breast cancer case diagnosed below the age of 36 years (p = 0.017). Of the 18 hboc families with fewer than 3 cases of breast cancer, half of the 10 mutation-positive families contained at least 1 breast cancer case diagnosed below the age of 36 years as compared with no cases diagnosed in mutation-negative hboc families in this sub-group. These observations reaffirm the significance of the presence of very young age of diagnosis of breast cancer with hbc and hboc families and should facilitate decisions aimed at genetic testing for BRCA mutations.

Breast Cancer at Less Than 36 Years of Age Is a Strong Predicator of BRCA1/2 Status in French-Canadian Cancer Families
Considerable differences exist between countries in the mutation probability methods and thresholds used to select patients for BRCA1 and BRCA2 genetic testing.
Objectives: To assess the efficiency of the mutation probability methods brcapro and Myriad, as compared with criteria based on cancer history in the family, to select patients eligible for BRCA1/2 mutation detection.

Methods:
We retrospectively calculated the brcapro and Myriad probabilities in 307 probands who had previously been selected for dna analysis according to a list of eligibility criteria based on number of first-and seconddegree relatives affected with breast cancer (bc) and/or ovarian cancer (oc), age of diagnosis, presence of bilateral bc, and bc in men. Until the year 2000, dna analysis was performed using the protein truncation test (ptt). The dna from patients in whom no mutation was initially found using the ptt later on underwent complete genetic screening.
Results: The ptt detected 21 mutations (6.5%); complete genetic screening identified an additional 32 mutations (10.4%) and 11 unclassified variants (uvs-3.6%). Compared with cancer history, a threshold of 10% with brcapro or with Myriad excluded about 40% of the patients from analysis, including 4 patients with a mutation and probabilities under 10% with both programs. all 4 probands had a BRCA2 mutation. The brcapro and Myriad methods showed similar specificity at 10% threshold, and overall, brcapro was more sensitive than Myriad. Only 2 of the probands with a uv had probabilities above 20% with brcapro and Myriad.
Conclusions: The mutation probability models brcapro and Myriad are economically more efficient than are cancer history criteria alone. For the detection of BRCA1 mutations, brcapro, at a 10% threshold, is equally sensitive; however, for BRCA2 mutations, cancer history is the most sensitive. Most of the patients with a uv have low probabilities with both methods, which may be an indicator of the lack of pathogenicity of those uvs.

Introduction:
There are 2 founder mutations in BRCA1 and 1 founder mutation in BRCA2 that are present in up to 2.5% of ashkenazi Jewish women. To date, it has not been proposed that the entire female Jewish population be eligible for screening. However, given the high frequency of mutations in the Jewish population at large, a full-population approach may be rational. Current guidelines for genetic testing in Ontario, Canada, stipulate the family history of cancer that must be present to confer eligibility for testing. little is known about the appropriateness of these guidelines in the Jewish population and the acceptance of genetic testing in this group of women.
Methods: Eligible subjects were women who self-identified as (Ashkenazi or Sephardic) Jewish, who were between the ages of 25 and 80 years, and who resided in Ontario. Study subjects were recruited through a description of the study that was published in a national newspaper on a single occasion in May 2008. Women were asked to complete a study questionnaire and a family history questionnaire, and to provide a blood or saliva sample. risks of mutation were estimated for each woman using ibis software.
Results: The overall mutation prevalence in the 2080 women who enrolled in the study was 1.1% (0.5% in BRCA1 and 0.6% in BRCA2). Of the 22 families, 10 (45%) would have met the criteria for genetic testing for BRCA1 and BRCA2 under current guidelines from the Ontario Ministry of Health and long-Term Care. There were no differences in risk of mutation for those with and without a BRCA1 or BRCA2 mutation (3.9% vs. 1.2%, p = 0.23). However, estimates of mutation risk for women with a BRCA1 mutation were higher than for those without a mutation (7.6% vs. 1.2%; p ≤ 10-4). This was not observed for women with a BRCA2 mutation compared with those with no BRCA mutation (0.8% vs. 1.2%; p = 0.32).
Conclusions: The prevalence of BRCA mutations in unselected Jewish women from Ontario, Canada, was lower than previously reported. However, many of the women would not have met the criteria for testing based on family history of cancer. Population screening for BRCA mutations should be considered for the Jewish population.

Recruitment of a Population-Based Sample of Black Women for a Study of Inherited Breast Cancer Using a Cancer Registry-Based Approach T. Pal, S. Vadaparampil. Moffitt Cancer Center, Tampa, Florida, U.S.A.
Objectives: We investigated BRCA1 and BRCA2 (BRCA) mutations in a population-based sample of black women diagnosed with breast cancer below the age of 50 years, because of the disproportionate numbers affected with early-onset breast cancer. Furthermore, because black people are typically underrepresented in genetic research studies, we sought to understand the factors associated with recruitment activities and study participation.
Methods: Following intuitional research board approvals, the State Cancer registry released demographic, clinical, and contact information on all eligible participants. State-mandated recruitment methods included 2 mailings, 3 weeks apart, with a telephone response card for patients who did not wish to be contacted by telephone. If no patient response was received within 3 weeks of the second mailing, a member of the study team contacted the patient by telephone. Participation involved a genetic counselling session over the telephone, and collection of blood or saliva for BRCA testing.
Results: Of the 209 eligible patients identified by the cancer registry, contact was established with 87, of whom 82 were eligible for study participation. The overall rate of interest in study participation was 80% (including 93% for passive follow-up and 68% for active follow-up), of whom 48 have been consented to date. There were no differences in the clinical and demographic characteristics of participants and nonparticipants.
Conclusions: This is the first study conducted through a State Cancer registry in which the primary goal was to recruit participants for genetic counselling and testing for inherited breast cancer. Use of active follow-up methods was important in study recruitment. In contrast with many earlier studies, our results suggest that black women with early-onset breast cancer are interested in participating in studies of genetics and breast cancer, indicating that participation rates in black women may be enhanced by carefully considering methods to facilitate participation. K. Panabaker, N. Scanlan, T. Paling, P. Ainsworth, J. Jung. London Health Sciences Centre, London, Ontario, Canada. deleterious mutations in the BRCA1/2 genes have not been identified in high-risk families as often as originally expected. In clinical practice, predictions of BRCA1/2 mutation probability are sometimes made using various statistical models. When such models are applied to the same person, a wide range of probabilities is revealed. although trying to provide best practice to patients, economic challenges also exist in the health care environment. For these reasons, the Cancer Genetics team at the london Health Sciences Centre critically evaluated our experiences regarding cancer risk assessment and our associated BRCA1/2 mutation detection rate. In Ontario in 2000, a provincial committee established 13 eligibility criteria for hereditary breast/ovarian cancer (hboc) screening based on the medical literature at that time, offering gene analysis to individuals with a perceived 10% or greater risk of having a BRCA1/2 gene mutation. The methodology of this study included a review of all pedigrees, of eligibility criteria, and of genetic test results of individuals (n = 1270) who participated in index BRCA1/2 testing from 2000 to 2008. a consistent approach to determining which eligibility criteria were used in each case was pertinent to the analysis. The results revealed that one of the criteria (3 or more cases of breast and/or ovarian cancer, any age), representing 48% (608/1270) of all individuals tested, reported a 12.3% (75/608) overall mutation detection rate. However, a subset of this group (3 or more cases of breast cancer, age over 50 years), representing 31% (189/608) of this category, showed only a 2.6% (5/189) positivity rate. Using a conservatively priced hboc screen ($1500), it takes approximately $56,000 to detect 1 mutation-positive individual in this subset. This finding could represent a significant cost savings to the current service testing program in Ontario. Our next goal is to determine if other cancer genetics programs in Ontario experience similar results in their own region, to provide further evidence to influence provincial decision-making.

Critical Evaluation of BRCA1/2 Mutation Detection Rates in Southwestern Ontario
Objectives: BRCA1/2 carriers face a 50% chance that mutations will be transmitted to their offspring, and concern about passing on BRCA1/2 is a common reason for genetic testing. Pre-implantation genetic diagnosis (pgd) is a promising technology for BRCA carriers. Pre-implantation genetic diagnosis is a type of assisted reproductive technology that involves genetic analysis of embryos obtained through in vitro fertilization. Couples can transfer only mutation-free embryos to the mother's uterus to initiate pregnancy. However, use of pgd for adult-onset cancer susceptibility is also controversial. as health care professionals increasingly become involved in discussions of family planning and reproductive technologies in their work with hereditary breast/ovarian cancer, the viewpoints of patients may provide insight for genetic counsellors and physicians attempting to navigate this ethically complex terrain. We report findings of a qualitative investigation of the views of reproductive-age BRCA1/2 mutation carriers regarding pgd, focusing on suggestions for integrating pgd into medical practice.
Methods: Reproductive-age patients (n = 22; 21 women, 1 man; 91% European American), recruited from the clinical genetics service of a national comprehensive cancer centre, participated. Participants view a brief presentation regarding pgd for BRCA1/2 mutations, followed by an in-depth interview about their attitudes toward using pgd to prevent transmission of BRCA1/2 mutations, including their suggestions for discussing pgd in the context of cancer-risk counselling. Interviews are recorded and transcribed verbatim, and analyzed using methods of grounded theory.
Results: Themes regarding information management-including timing, delivery, and depth-were discussed. although most participants want some information about pgd, suggesting it is "at least glossed over" in the initial counselling session, many emphasized that information should be limited, maintaining the focus on the patient undergoing testing/counselling.
Conclusions: BRCA1/2 mutation carriers are interested in learning about pgd; physicians and genetic counsellors must be prepared to discuss this technology. Suggestions are provided for tailoring information to the needs and values of patients.

To Test or Not to Test: The Influence of Ashkenazi Jewish Ethnicity
N. Schonberger. Sharsheret, Teaneck, New Jersey, U.S.A.
Cancer genetic counsellors are well aware of the increased risk for individuals of ashkenazi Jewish background carrying a BRCA mutation and of the fact that breast/ovarian cancer is more likely to have a genetic basis in Jewish than in non-Jewish families. What they may not be as familiar with, is the existence of a community of mainly religious Jewish women who are resistant to genetic counselling/testing because of unique issues surrounding their religious beliefs. Some Jewish women may find that breast/ovarian cancer treatments and/or genetic testing present religious dilemmas above and beyond the emotional dilemmas that all women confront with cancer. When faced with a diagnosis of breast or ovarian cancer, these women have questions and specific psychosocial concerns that may not be understood by the general cancer community, including genetic counsellors and cancer support groups. Some of their concerns surround issues of community, the Mikvah (ritual bath), and cancer as a stigma affecting marriage prospects. These questions need to be addressed by sources knowledgeable in Jewish lore and practices. A national, not-for-profit organization was formed several years ago to address these unique psychosocial, genetic, and practical issues pertinent to Jewish women living with or at high risk of breast cancer. acquaintance with this organization and an in-depth description of these issues will be the substance of this poster, so that professionals who meet with resistance on the part of their Jewish patients will have a better understanding of how to give them the support they need within the parameters of Jewish religious customs.